Population Health in a Post-Fee-For-Service World, with Grace Terrell at Cornerstone Health Care

Grace Terrell is the CEO of Cornerstone Health Care, a 250-physician, multi-site, multispecialty group practice in the Piedmont Triad region of North Carolina; it’s an Accountable Care Organization, and it is in value-based contracts with 100% of its commercial payors. Spread out over 85 different practice sites in a largely rural area, it sees 250,000 patients annually. All of these factors come together in a way that allows Cornerstone to practice population health, and to address chronic disease in a holistic manner that is not usually done in a traditional fee-for-service practice.

In discussing cost and quality, Dr. Terrell focused on diabetes:

One of the things, obviously, that is one of the biggest challenges in population health has to do with diabetes and its enormous impact that it has on quality for life for patients and its increasing prevalence, particularly as the population is aging.There’s not a contract out there that we have that doesn’t focus on diabetes as the first and foremost population health issue to tackle within the context of both the cost as well as looking at quality parameters.So a lot of the focus that we have seen has been evaluating what sort of ways we can put things in place to really address that part of our patient population.

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The way we begin thinking about a population of patients is that they are different. You have got the healthy patients, you have got those that are at risk for chronic disease, you have got those who are with early or controlled chronic diseases, you have got those with late, end-stage polychronic illness, you have got acute problems and then you have got the frail elderly or those that are at the end of life. The way we basically worked through this is saying, okay, let’s just assume that if you were going to start from scratch you wouldn’t treat everybody the same with a 15-minute office visit, what you would do would be to say, how might we approach these different groups?

Cornerstone has designed a tailored approach that helps reach patients at various stages of chronic illness, and that improves metrics and outcomes for a significant portion of the patient population.

Join Grace Terrell at Diabetes Innovation 2013, and hear more about her approach to chronic care management in a post fee-for-service environment.

David Harlow: This is David Harlow for Diabetes Innovation. I have with me today Grace Terrell from Cornerstone Health Care in the great state of North Carolina. Welcome.

Grace Terrell: Thank you.

David Harlow: Please tell us if you would, in a few words, about your practice, where you are located, what kind of patients you are seeing and what you are doing to hack diabetes?

Grace Terrell: Okay. Cornerstone Health Care is a multi-specialty medical practice in the Piedmont Triad area of North Carolina, which is the Greensboro-Winston-Hickory area. It is in High Point and it is a practice that is about 50% primary care, 50% specialist who are in about 85 different practice sites over a 2-hour sort of driving distance between two sort of ends off. We have our own staff at 15 different hospitals, reporting to 8 different health systems. We also are an Accountable Care Organization, where in the context that we have decided to focus all of our energies on moving from volume to value and have 100% of our contracts now in a value-based contract such that we are paid for improving population health — including quality parameters as well as efficiencies in costs.

David Harlow: Sure, you said a 100% of your contracts are now value-based payments?

Grace Terrell: Yes.

David Harlow: Is there any other organization in your state that could make a similar claim?

Grace Terrell: I don’t think so but we have got a lot of other organizations in our state that are also well on the road to be value-based organizations including several Accountable Care Organization that have some contracts both commercial or Medicare Shared Savings.

David Harlow: Great, I believe I cut you off — you were starting to talk about some of the quality measures that you are looking at ….

Grace Terrell: One of the things, obviously, that is one of the biggest challenges in population health has to do with diabetes and its enormous impact that it has on quality for life for patients and its increasing prevalence, particularly as the population is aging. There’s not a contract out there that we have that doesn’t focus on diabetes as the first and foremost population health issue to tackle within the context of both the cost as well as looking at quality parameters. So a lot of the focus that we have seen has been evaluating what sort of ways we can put things in place to really address that part of our patient population.

David Harlow: How has that led you to change your care delivery model? — and before getting into the specifics of that, you mentioned before that you have a very large number of practice sites. I’m imagining that some of them are with relatively small number of clinicians present at each site, is that correct?

Grace Terrell: Yes. There’s many in some rural areas and some of those practices have a larger number of physicians, some of them are aggregated into a couple of large ambulatory centers but a lot of North Carolina, if you haven’t been here, is rural and a lot of area we serve, even though we are in an urban area, is well, goes out into some of the smaller communities where there is still small family practices or internal medicine or pediatric practices.

David Harlow: Sure, and so the total patient population that you serve is approximately how large?

Grace Terrell: We have got about 250 physicians and about at this point 120 advance practice providers such as nurse practitioners, clinical nurse specialists or physician assistants.

David Harlow: Great. Okay. So we are starting to talk about the move from volume to value and what that means in terms of caring for a population and looking at markers for diabetes, quality measures for diabetes and dealing with patients with diabetes. The question then for me is how has this move changed the approach to practice in the office?

Grace Terrell: Up until recently, I think the way that most people thought about health care was very provider-centric, either hospital-centric or physician-centric, in the context that it had to do with the way we were paid and it was about the 15-minute office visit. The patient came in to the office and everybody had the same sort of way of interacting with the health care system, which was you got your visit, some talk occurred, some physical exam occurred, some tests occurred and then some information or procedures were pushed back out to the patient. Well, that may be the right kind of approach in the old days but it’s not very patient-centered and it’s not a really good way of thinking about things comprehensively from a population standpoint.

The way we begin thinking about a population of patients is that they are different. You have got the healthy patients, you have got those that are at risk for chronic disease, you have got those who are with early or controlled chronic diseases, you have got those with late, end-stage polychronic illness, you have got acute problems and then you have got the frail elderly or those that are at the end of life. The way we basically worked through this is saying, okay, let’s just assume that if you were going to start from scratch you wouldn’t treat everybody the same with a 15-minute office visit, what you would do would be to say, how might we approach these different groups?

Within the context of diabetes, we basically have several new types of things that we are doing. The first was, that we said, are there patients out there in the world who have gaps in care such as hemoglobin A1c greater than 8 and LDL that was not to goal or blood pressure that was not controlled, who haven’t seen a primary care physician within 6 months. With that we were able to identify those patients with some analytic tools that we have invested in and rather than making it all about the patient that is in front of us in the office, we said what about those that are not in the office. We hired some very good customer-service-trained nursing assistants usually by background or medical assistants by background so they had some health care knowledge and trained them to be what we call our “patient care advocates.”

The first thing we did we homed in on our diabetic patients with those criteria of gaps in care or poor control and we just simply called them up and invited them to come back in to see us. This was an outreach and we were able to identify patients that were out there in the world not receiving care. Another thing that we did is we then went in and we started risk-stratifying our patients into those groups that we talked about before and for those that had what are high Charlson scores, which is a severity index for illness. We created a couple of practices that were specifically related to them. We have patients with typically five or six chronic illness, nearly all of them have diabetes because that tends to be one of the ones that goes along with so many others and we created teams of people that were to basically not have the tyranny of the 15-minute office visit but just spend as much time with them as possible, when and how and where it needed to be. They may come in and have a two-hour office visit the first time and there would be a team involving navigators and it would involve care coordinators and disease management specialists, nurse practitioners and a physician leading those teams.

Then we have also with a major pharmaceutical chain, I don’t think they are wanting this announced yet, but we have been having a beta site where we actually have health coaches in the pharmacy that’s working on medication adherence and other types of things such as diet, exercise, smoking cessation, weight loss — specifically with these same patients. That’s sort of three things we are doing, polychronic clinics, the patient care advocates, and the health coaching with the pharmacy partner.

David Harlow: Well, that sounds great. I guess my question about reaching out to patients who are at risk and who haven’t been in to see you recently would be this: How do you motivate people who have managed to avoid the office visit to come in?

Grace Terrell: One of the things that we have found with the patient care advocates calling is that quite often we find it’s because they have had a bad experience or it may be because they are feeling bad about not doing well. I will give you a personal example. There was a patient of mine — I’m a general internist and still see patients a couple of mornings a week — that had come in about a year ago to see me and I had made the diagnosis of Type 2 diabetes early onset and had – this is before we had any of this in place or this was a couple of years ago. What I did is I did what I usually do which I ordered up all the stuff that needed to be done including a consult with a nutritionist and eye exam, the immunizations and all that and basically with a 3-month followup to see me back.

Well, the patient didn’t come back and in the world that we were in, I don’t know if I would have identified that patient. When the patient care advocate identified that the patient had skipped the appointment, she called the patient, and she found out a couple of things and one of those things she found out was that her mother had died of diabetes and she had wanted to try diet and exercise and all that but she was really afraid of the diagnosis. She was able to have that conversation with the patient care advocate, who was very empathetic, and the patient care advocate put a note on the chart so when she came in to see me I was able to start probably from a different place which is not talking about adherence or compliance or any of the things that physicians tend to focus on but getting her to talk about her feelings about the disease. She is doing well and she is one example. It’s just that human stuff, it’s reaching out to people and it doesn’t work all the time. I think we have been monitoring. We have about a 60% success at bringing them in if they need to come in and have not and they have been lost to the system. Of those, we have a very high improvement rate in their blood sugar and lipid and blood pressure control. We are not getting everybody but we are starting to make a little bit of a difference.

David Harlow: Do you have a – can you share with me some examples of targets that maybe built into some of your payor contracts in terms of quality measures, are you trying to achieve improvements through interventions on A1C levels or are we looking at something different than that or something broader than that?

Grace Terrell: It just depends. We have different payors focused on different things. For some of them, it is the HbA1C less than 8 for example, or HbA1C is controlled; for others, it maybe be a lipid level, LDL Cholesterol level that’s below 100 in somebody with a diagnosis of coronary disease, vascular disease or diabetes. There are different ones and different levels from the different payors. What we have chosen to do is take the approach that we want to be better or as good as our highest goal for every single one of these contracts. If one contract says, you need to have – I’m just making up numbers, but you need have 50% of your diabetics with A1C less than 8 and then another one says you need to have 90%, then we make 91% our Cornerstone goal for success. We basically hold our success up to whatever the highest one is, assuming that all boats will be lifted by doing it that way. A lot of it is things like the American College of Endocrinology and American Diabetic Association — appropriate diabetic goals are the ones that are built into this and a lot of contracts are about what percentage of your population meets these goals.

David Harlow: Doing all this, of course, is more expensive than a traditional primary care practice has been in the past and I’m wondering whether you are being compensated appropriately by the plans since some of the savings would be experienced not only in the speciality care within the physician group but within the hospitalization. Does this all work out, did this go in to the calculation of appropriate value-based payments up front?

Grace Terrell: All the value-based contracts are based upon the concept that there will be a shared savings component off the overall cost of care that can be shared or it can be a full risk contract and in North Carolina that’s something that we are not used to yet, we’ll be doing it shortly but we don’t have those yet. The way a lot of these things work and there are different contracts with different people, different individuals, it is quite often there will an additional payment to primary care for management as opposed to — a per member, per month type management fee, to partially offset the cost of these services. Then the other side of it that there is a lookback at the end of the contract and there is a percentage savings that is calculated that goes back to the practices. In order for us to achieve that we have to both save money and make quality parameters.

In full risk contracts, like a lot of the country is been used to for years, it is not present right now in North Carolina, there is money paid upfront and then you have the money from which you just make your decisions about investing. With the Medicare Shared Savings Program as well as the type of commercial contracts that are coming on the market in North Carolina, you have to make the investment upfront except for some portion with some of the contracts might have a primary care management fee with the hopes that if you are successful you are going to get it on the backside at the lookback.

David Harlow: It is certainly an issue to be conscious of but it sounds like it has been dealt with in the contracts that you have.

Grace Terrell: As well as we can.

David Harlow: Right. It sounds like you have been doing quite a lot on this front and it is interesting to hear that you and your payer partners have seen diabetes as sort of a touchstone and a place to focus efforts as it brings folks in who have other diseases, other complications, but all tied back one way or another to the diabetes diagnosis. Are you expanding this program to include folks with pre-diabetes or talking about prevention as well?

Grace Terrell: We have other efforts underway that are thinking about that portion of the population and you make a very good point. It is not just about treating those who already have disease that’s far along from a chronicity standpoint but it is preventing others. The first place in the contracts to go with those that are the sickest because that’s where the most potential savings and improvement can be but as we get better with this, what needs to happen next is a much larger focus on prevention such as you are talking about. So, Cornerstone is large enough to be self insured so one of the first things that we are doing right now is with our own employee population – we’ve got about 1800 employees – we are creating and designing our own benefits around certain aspects of wellness so that we if have wellness behaviors, if our employees do certain things, then there is a benefit to them in our benefits design.

In addition, we have actually talked about and are looking at our own early diabetic or pre-diabetic in our employee population and seeing if we can create some benefits designed to address those exact things. For example, ought there to be certain medications that are free of any co-pay? Ought there to be free membership in gyms? This is a conversation that we are having right now at the level of our own HR department and we believe that if we are able to come up with something on our own selves that is helpful then as we partner with other employers in the community and payors in general then we can give them evidence that we practice what we preach and that it makes a great deal of impact in the long run.

David Harlow: That sounds great. What do you hope to learn or what kinds of people do you hope to meet when you come to the Diabetes Innovation conference in DC?

Grace Terrell: That’s a great question. I learn so much the minute that I leave my own community because everybody out there is so smart and they are trying, I totally believe that most physicians and others in health care want to do the right thing. We are in a very, very tough time in health care delivery system and when you get a bunch of folks together that are excited about talking about innovation, then everybody wins and everybody benefits. We have never minded sharing some of our ideas and other things we are doing in Cornerstone and don’t claim that any of them are particularly invented by us. There are types of things that we just all need to put in to place. I am looking forward to hearing what other people are doing and figure out how we can make what we are doing better and apply that in ways that we haven’t done here yet. I am very much looking forward to it.

David Harlow: Well, I am sure others will be benefiting from learning from you as well.

Well, thank you very much. I have been speaking with Dr. Grace Terrell, Chief Executive Officer of Cornerstone Health Care. This is David Harlow for Diabetes Innovation.